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•Intermanual transfer is observed in a sequence learning task, independently of the trained hand's performance.•Pre-training connectivity strength between premotor cortex and nodes within visual attention and executive control networks correlates with transfer.•Intermanual transfer is associated with functional connectivity changes within the motor network after training. Intermanual transfer of motor learning is a form of learning generalization that leads to behavioral advantages in various tasks of daily life. It might also be useful for rehabilitation of patients with unilateral motor deficits. Little is known about neural structures and cognitive processes that mediate intermanual transfer. Previous studies have suggested a role for primary motor cortex (M1) and the supplementary motor area (SMA). Here, we investigated the functional neuroanatomy of intermanual transfer with a special emphasis on functional connectivity within the motor network and between motor regions and attentional networks, including the fronto-parietal executive control network and visual attention networks. We designed a finger tapping task, in which young, heathy subjects trained the non-dominant left hand in the MRI scanner. Behaviorally, transfer of sequence learning was observed in most cases, independently of the trained hand's performance. Pre- and post-training functional connectivity patterns of cortical motor seeds were investigated using generalized psychophysiological interaction analyses. Transfer was correlated with the strength of connectivity between the left premotor cortex and structures within the dorsal attention network (superior parietal cortex, left middle temporal gyrus) and executive control network (right prefrontal regions) during pre-training, relative to post-training. Changes in connectivity within the motor network, and more particularly between trained and untrained M1, as well as between the SMA and untrained M1, correlated with transfer after training. Together, these results suggest that the interplay between attentional, executive and motor networks may support processes leading to transfer, whereas, following training, transfer translates into increased connectivity within the motor network.

Background Prediction of outcome after stroke is critical for treatment planning and resource allocation but is complicated by fluctuations during the first days after onset. We propose a machine learning model that can provide hourly predictions based on the integration of continuous variables acquired within 72 h of hospital admission. Methods We analyzed 2492 admissions for ischemic stroke in the Geneva University Hospital from 01.01.2018 to 31.12.2021, amounting to 2’131’752 unique data points. We developed a transformer model that continuously included clinical, physiological, imaging, and biological data recorded within 72 h of admission. This model was trained to generate hourly predictions of mortality and morbidity. Shapley additive explanations were used to identify the most relevant predictors to explain outcomes for each patient. The MIMIC-III database was used for external validation. Results Our transformer model predicts mortality, with an area under the receiver operating characteristic curve of 0.830 (95% CI 0.763–0.885) on admission, reaching 0.893 (95% CI 0.839–0.933) 72 h later for a 3-month outcome. Validated in an independent cohort, it outperforms all static models. Based on their mean explanatory weights, the top predictors included continuous clinical evaluation, baseline patient characteristics, timing from admission to acute treatment, and markers of inflammation and organ dysfunction. Conclusions The performance of our transformer model demonstrates the potential of machine learning models integrating clinical, physiological, imaging, and biological variables over time after stroke. The clinical applicability of our model is further strengthened by access to hourly updated predictions along with accompanying explanations. Plain language summary Stroke is the most frequent cause of disability in industrialized countries. To determine the best treatment and allocate resources, an early and accurate prediction of outcome is essential. Although modern stroke units gather a continuous stream of data, existing tools for outcome prediction are rarely used as they are static and fail to adapt to the evolving condition of the patient. We developed a machine learning model, a computer system learning from existing data, to provide real-time predictions of in-hospital mortality and 3-month outcomes. Our model was able to provide accurate hourly prediction of outcome based on regularly updated clinical data obtained from the patient. This study demonstrates the potential of integrating the continuous data stream recorded in the electronic health record after stroke. Similar predictive models could help personalize treatment planning, empower patients and their families through counseling, and facilitate resource allocation. Klug et al. present a machine learning model for continuous monitoring and prediction of functional outcome after acute ischemic stroke. Integrating clinical, physiological, and biological variables over time, the system detects patients at risk as well as potential causes of deterioration.

Although prevention of dementia and late-life cognitive decline is a major public health priority, there are currently no generally established prevention strategies or operational models for implementing such strategies into practice. This article is a narrative review of available evidence from multidomain dementia prevention trials targeting several risk factors and disease mechanisms simultaneously, in individuals without dementia at baseline. Based on the findings, we formulate recommendations for implementing precision risk reduction strategies into new services called Brain Health Services. A literature search was conducted using medical databases (MEDLINE via PubMed and SCOPUS) to select relevant studies: non-pharmacological multidomain interventions (i.e., combining two or more intervention domains), target population including individuals without dementia, and primary outcomes including cognitive/functional performance changes and/or incident cognitive impairment or dementia. Further literature searches covered the following topics: sub-group analyses assessing potential modifiers for the intervention effect on cognition in the multidomain prevention trials, dementia risk scores used as surrogate outcomes in multidomain prevention trials, dementia risk scores in relation to brain pathology markers, and cardiovascular risk scores in relation to dementia. Multidomain intervention studies conducted so far appear to have mixed results and substantial variability in target populations, format and intensity of interventions, choice of control conditions, and outcome measures. Most trials were conducted in high-income countries. The differences in design between the larger, longer-term trials that met vs. did not meet their primary outcomes suggest that multidomain intervention effectiveness may be dependent on a precision prevention approach, i.e., successfully identifying the at-risk groups who are most likely to benefit. One such successful trial has already developed an operational model for implementing the intervention into practice. Evidence on the efficacy of risk reduction interventions is promising, but not yet conclusive. More long-term multidomain randomized controlled trials are needed to fill the current evidence gaps, especially concerning low- and middle-income countries and integration of dementia prevention with existing cerebrovascular prevention programs. A precision risk reduction approach may be most effective for dementia prevention. Such an approach could be implemented in Brain Health Services.

BackgroundDirect thromboaspiration has been reported as an effective mechanical treatment for acute ischemic stroke. We aimed to determine whether the angle of interaction between the aspiration catheter and the clot affects the success of clot removal in ischemic stroke patients with large vessel occlusion in the anterior and posterior circulation.MethodsAll patients treated at our institution by direct thromboaspiration as a firstline technique between January 2016 and December 2017 were enrolled in the study. We retrospectively reviewed baseline and procedural characteristics, the angle of interaction formed between the aspiration catheter and the clot, the modified Thrombolysis in Cerebral Infarction score, and the 3 month modified Rankin Scale score.Results85 patients underwent direct thromboaspiration as the firstline treatment during the study period. 100 direct thromboaspiration passes were performed. An angle of interaction of ≥125.5° significantly influenced the success of clot removal (P<0.001) with good sensitivity and specificity, in particular for occlusion of the middle cerebral and basilar artery. The combination of aspiration with a stent retriever based thrombectomy was a valid rescue treatment in cases of standalone direct thromboaspiration failure.ConclusionsIn our series, an angle of interaction between the aspiration catheter and the clot of ≥125.5° was significantly associated with successful clot removal. The prediction of the angle of interaction on pretreatment imaging may help operators to select the most adequate mechanical thrombectomy technique on a case by case basis.

Stroke treatment has significantly improved over the last decades, but the complexity of stroke cases requires specialized care through dedicated teams with specific knowledge and training. The National Institutes of Health Stroke Scale (NIHSS), widely used to assess neurological deficits and make treatment decisions, is reliable but requires specific training and certification. The traditional didactic training method, based on a video, may not adequately address certain NIHSS intricacies nor engage health care professionals (HCPs) in continuous learning, leading to suboptimal proficiency. In the context of time-constrained clinical settings, highly interactive e-learning could be a promising alternative for NIHSS knowledge acquisition and retention. This study aimed to assess the efficacy of a highly interactive e-learning module compared with a traditional didactic video in improving NIHSS knowledge among previously trained HCPs. Furthermore, its impact on knowledge retention was also assessed. A prospective, multicentric, triple-blind, and web-based randomized controlled trial was conducted in 3 Swiss university hospitals, involving HCPs previously trained in NIHSS. Invitations were sent through email, and participants were randomized to either the e-learning or traditional didactic video group through a fully automated process upon self-registration on the website. A 50-question quiz was administered before and after exposure to the training method, and scores were compared to assess knowledge acquisition. The quiz was repeated after 1 month to evaluate retention. Subjective assessments of learning methods that is, user satisfaction, probability of recommendation, perceived difficulty, and perception of duration, were also collected through a Likert-scale questionnaire. A sample size of 72 participants were deemed necessary to have an 80% chance of detecting a difference of 2 points in the postcourse quiz between groups at the 5% significance level. Invitations to participate were sent through email to an estimated 325 HCPs. 174 HCPs enrolled in the study, of which 97 completed the study course. Both learning methods significantly improved NIHSS knowledge, with an improvement of 3.2 (range 2.0-4.3) points in the e-learning group and of 2.1 (1.2-3.1) points in the video group. However, the e-learning group performed better, with higher scores in knowledge acquisition (median score 39.0, IQR 36.0-41.0 vs 37, IQR 34.0-39.0; P=.03) and in knowledge retention (mean score 38.2, 95% CI 36.7-39.7 vs 35.8, 95% CI 34.8-36.8; P=.007). Participants in the e-learning group were more likely to recommend the learning method (77% vs 49%, P=.02), while no significant difference was found for satisfaction (P=.17), perceived duration (P=.17), and difficulty (P=.32). A highly interactive e-learning module was found to be an effective asynchronous method for NIHSS knowledge acquisition and retention in previously NIHSS-trained HCPs, and may now be considered for inclusion in NIHSS training programs for HCPs. RR2-10.3390/healthcare9111460.

Background Fever is associated with worse outcomes in patients with acute brain injury. Diclofenac, a non-steroidal anti-inflammatory drug, is commonly used as antipyretic therapy. As evidence emerged that short diclofenac infusions (< 1 h) decrease brain tissue oxygen (PtO2) and cerebral perfusion pressure (CPP), clinical practice has shifted to extended infusions (12 h). The purpose of this study was to investigate the effects of extended diclofenac infusion for the treatment of fever on cerebral perfusion and tissue oxygenation after acute brain injury. Results We conducted a retrospective study of prospectively collected data from a cohort of 18 patients with acute brain injury and PtO2 monitoring admitted between November 2018 and April 2024. The hour before and the 12 h during an extended diclofenac infusion were compared. Additionally, we compared the 12 h prior and 12 h during the diclofenac infusion. Cerebral autoregulation and metabolites obtained by microdialysis were assessed in a subgroup of patients. Thirty-nine interventions were analyzed. Core temperature decreased from 38.1°C in the hour before to 37.4 °C during an extended diclofenac infusion ( p  < 0.0001). ICP (11.0 vs 10.0 mmHg, p  < 0.0001) and heart rate (84 vs. 77 bpm, p  < 0.0001) decreased. CPP and PaCO2 did not vary significantly. PtO2 decreased from 23.1 mmHg (IQR 19.0–31.4) during fever peak to 21.7 mmHg (IQR 17.8–27.2) ( p  < 0.0001). Median PtO2 during the 12 h before diclofenac was 23.3 mmHg (IQR 18.9–30.5). In a multivariable analysis the effect of treatment was significantly influenced by heart rate and temperature ( p  < 0.0001). Conclusions Extended diclofenac infusions for the treatment of fever in patients with acute brain injury achieve a clinically significant reduction in temperature but are associated with a small decrease in PtO2, even in the setting of maintained CPP.

Dementia has a devastating impact on the quality of life of patients and families and comes with a huge cost to society. Dementia prevention is considered a public health priority by the World Health Organization. Delaying the onset of dementia by treating associated risk factors will bring huge individual and societal benefit. Empirical evidence suggests that, in higher-income countries, dementia incidence is decreasing as a result of healthier lifestyles. This observation supports the notion that preventing dementia is possible and that a certain degree of prevention is already in action. Further reduction of dementia incidence through deliberate prevention plans is needed to counteract its growing prevalence due to increasing life expectancy. An increasing number of individuals with normal cognitive performance seek help in the current memory clinics asking an evaluation of their dementia risk, preventive interventions, or interventions to ameliorate their cognitive performance. Consistent evidence suggests that some of these individuals are indeed at increased risk of dementia. This new health demand asks for a shift of target population, from patients with cognitive impairment to worried but cognitively unimpaired individuals. However, current memory clinics do not have the programs and protocols in place to deal with this new population. We envision the development of new services, henceforth called Brain Health Services, devoted to respond to demands from cognitively unimpaired individuals concerned about their risk of dementia. The missions of Brain Health Services will be (i) dementia risk profiling, (ii) dementia risk communication, (iii) dementia risk reduction, and (iv) cognitive enhancement. In this paper, we present the organizational and structural challenges associated with the set-up of Brain Health Services.

Background Stroke in the course of coronavirus disease (COVID-19) has been shown to be associated with more severe respiratory symptoms and higher mortality, but little knowledge in this regard exists on older populations. We aimed to investigate the incidence, characteristics, and prognosis of acute stroke in geriatric patients hospitalized with COVID-19. Methods A monocentric cross-sectional retrospective study of 265 older patients hospitalized with COVID-19 on acute geriatric wards. 11/265 presented a stroke episode during hospitalization. Mortality rates and two-group comparisons (stroke vs non-stroke patients) were calculated and significant variables added in logistic regression models to investigate stroke risk factors. Results Combined ischemic and hemorrhagic stroke incidence was 4.15%. 72.7% of events occurred during acute care. Strokes presented with altered state of consciousness and/or delirium in 81.8%, followed by a focal neurological deficit in 45.5%. Ischemic stroke was more frequently unilateral (88.8%) and localized in the middle cerebral artery territory (55.5%). Smoking and a history of previous stroke increased by more than seven (OR 7.44; 95% CI 1.75–31.64; p  = 0.007) and five times (OR 5.19; 95% CI 1.50–17.92; p  = 0.009), respectively, the risk of stroke. Each additional point in body mass index (BMI) reduced the risk of stroke by 14% (OR 0.86; 95% CI 0.74–0.98; p  = 0.03). In-hospital mortality (32.1% vs. 27.3%; p  > 0.999) and institutionalization at discharge (36.4% vs. 21.1%; p  = 0.258) were similar between patients with and without stroke. Conclusion Incident stroke complicating COVID-19 in old patients was associated with active smoking, previous history of stroke, and low BMI. Acute stroke did not influence early mortality or institutionalization rate at discharge.

BackgroundSuccessful direct thromboaspiration (DTA) is related to several factors such as clot consistency, size, and location. It has also been demonstrated recently that the angle of interaction (AOI) formed by the aspiration catheter and the clot is related to DTA efficacy. The aims of this study were three-fold: (a) to confirm the clinical finding that the AOI formed by the aspiration catheter and the clot influence DTA efficacy; (b) to evaluate to what extent this influence varies according to differences in clot consistency and size; and (c) to validate stent retriever thrombectomy as an effective rescue treatment after DTA failure in the presence of an unfavorable AOI.MethodsA rigid vascular phantom designed to reproduce a middle cerebral artery trifurcation anatomy with three M2 segments forming different angles with M1 and thrombus analog of different consistencies and sizes was used.ResultsDTA was highly effective for AOIs >125.5°, irrespective of thrombus analog features. However, its efficacy decreased for acute AOIs. Rescue stent retriever thrombectomy was effective in 92.6% of cases of DTA failure.ConclusionsThis in vitro study confirmed that the AOI formed by the aspiration catheter and the thrombus analog influenced DTA efficacy, with an AOI >125.5° related to an effective DTA. Stent retriever thrombectomy was an effective rescue treatment after DTA failure, even in the presence of an unfavorable AOI.

BackgroundWe investigated outcomes in patients with intracerebral haemorrhage (ICH) according to prior anticoagulation treatment with Vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs) or no anticoagulation.MethodsThis is an individual patient data study combining two prospective national stroke registries from Switzerland and Norway (2013–2019). We included all consecutive patients with ICH from both registries. The main outcomes were favourable functional outcome (modified Rankin Scale 0–2) and mortality at 3 months.ResultsAmong 11 349 patients with ICH (mean age 73.6 years; 47.6% women), 1491 (13.1%) were taking VKAs and 1205 (10.6%) DOACs (95.2% factor Xa inhibitors). The median percentage of patients on prior anticoagulation was 23.7 (IQR 22.6–25.1) with VKAs decreasing (from 18.3% to 7.6%) and DOACs increasing (from 3.0% to 18.0%) over time. Prior VKA therapy (n=209 (22.3%); adjusted ORs (aOR), 0.64; 95% CI, 0.49 to 0.84) and prior DOAC therapy (n=184 (25.7%); aOR, 0.64; 95% CI, 0.47 to 0.87) were independently associated with lower odds of favourable outcome compared with patients without anticoagulation (n=2037 (38.8%)). Prior VKA therapy (n=720 (49.4%); aOR, 1.71; 95% CI, 1.41 to 2.08) and prior DOAC therapy (n=460 (39.7%); aOR, 1.28; 95% CI, 1.02 to 1.60) were independently associated with higher odds of mortality compared with patients without anticoagulation (n=2512 (30.2%)).ConclusionsThe spectrum of anticoagulation-associated ICH changed over time. Compared with patients without prior anticoagulation, prior VKA treatment and prior DOAC treatment were independently associated with lower odds of favourable outcome and higher odds of mortality at 3 months. Specific reversal agents unavailable during the study period might improve outcomes of DOAC-associated ICH in the future.